A macrosomic infant is born after a difficult delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse’s most appropriate action is to:
Leave the infant in the room with the mother.
Take the infant immediately to the nursery.
Monitor blood glucose levels frequently, and observe closely for signs of hypoglycemia.
Perform a gestational age assessment to determine if the infant is LGA.
The Correct Answer is C
Choice A rationale
Keeping the infant in the mother’s room without further evaluation increases the risk of missed complications like hypoglycemia. Monitoring and interventions are crucial for infants at risk due to macrosomia or difficult delivery.
Choice B rationale
Immediate nursery transfer without specific monitoring or intervention overlooks the infant’s risk for hypoglycemia and its symptoms, such as jitteriness or poor feeding. Further evaluation is more appropriate.
Choice C rationale
Macrosomic infants are at higher risk for hypoglycemia due to increased insulin levels post-birth. Frequent glucose monitoring and vigilance for signs like jitteriness or lethargy are crucial for timely intervention.
Choice D rationale
While gestational age assessment confirms LGA status, it does not address the immediate risk of hypoglycemia. Focus should remain on monitoring and stabilizing glucose levels in at-risk macrosomic infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Magnesium sulfate is primarily used for seizure prophylaxis in preeclampsia or eclampsia. It does not manage hemorrhagic conditions or uterine atony effectively, making it unsuitable for controlling postpartum hemorrhage.
Choice B rationale
Hemabate or Tranexamic Acid (TXA) addresses postpartum hemorrhage by promoting uterine contraction or inhibiting fibrinolysis. Hemabate is a prostaglandin, while TXA is an antifibrinolytic, both effective in hemorrhagic control.
Choice C rationale
Methergine (methylergonovine) induces uterine contraction to manage postpartum hemorrhage effectively but is contraindicated in hypertensive patients due to the risk of exacerbating hypertension or inducing stroke.
Choice D rationale
Nifedipine is a calcium channel blocker used to treat hypertensive disorders or preterm labor. It has no role in treating postpartum hemorrhage or enhancing uterine tone in such cases.
Correct Answer is B
Explanation
Choice A rationale
Tight swaddling does not address hypoglycemia but may increase the infant’s stress. Hypoglycemia requires immediate correction through feeding or IV glucose, as low glucose levels can impair neonatal neurologic function.
Choice B rationale
Feeding provides immediate glucose replenishment, correcting hypoglycemia, which manifests as trembling. Rechecking glucose ensures effective correction. Normal neonatal glucose levels are 45–65 g/dL, with intervention needed below 40 g/dL.
Choice C rationale
Monitoring urinary output is insufficient for managing neonatal hypoglycemia. Trembling indicates an acute need for glucose, requiring prompt feeding or IV glucose rather than passive observation of output.
Choice D rationale
Immediate NICU transfer is unnecessary unless hypoglycemia remains uncorrected or other complications arise. Prompt feeding and glucose recheck are adequate to stabilize the neonate in most cases.
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